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APPLICATION TOR PERMIT {2 //g:/ oiz /o SAN JOAQUIN,LOCAL,HEALTH DISTRICT 1601 E. HAZELTON.AVE., STOCKTON, CA ;Z 6-,Z i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM.DATE ISSUED - a (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made incompliance with San•Joaquin County Ordinance No.549 for sewage or No..1862 for.well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ �� Jab Address f�N so _�oR_tcgocio! 15!2 j a } City. '�J .Lot Size. 3z'J PM u Z _. ..." - ti Owner's Name --DEL/- Address /JMI Phone Contractor's Name zzLicense No. r -- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ „ PUMP INSTALLATION" C1 SYSTEM REPAIR ❑ OTHER ❑ xf DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES _ DISPOSAL FLD._ PROP. LINE, FOUNDATION !; AGRICULTURE WELL' OTHER WELL PITS/SUMPS t `� 7 INTENDED USE TYPE.OF WELL PROBLEM AREA,. CONSTRUCTION SPECIFICATIONS y - ElIndustrial - ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private' ' C1 Gravel Pack. ❑ Tracy Type of Casing Specifications ❑ Public' ( ❑ Other y + ' .y C] Delta Depth of Grout Seal $ Type of Grout ElIrrigation - epprox-Mepth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump' H.P. State Work Done * " Well Destruction ❑ Well Diameter ' SealingMaterial (top 50'1- - Iii " ._ , Depth Filler Material,(Below 50') k e C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO ::DESTRUCTION..❑INo septic`system permitted if public sewer is .- - available within 200 feet.) l Installation will serve: Residence Commercial Number of living units: Number of bedrooms y. r ,r y .. C r J �. itable depth Q !' Character.of soil to a depth of 3 feet: , � � _ SEPTIC TANK E3 ,Type/Mfg Capacity r s "'Wat rNo.'Compartmentsa ' PKG. TREATMENT.PLT}❑ Method of Disposal- Q Distance-to nearest: Well - Foundation Property Line l LEACHING LINE ❑ri No. &,Length of lines T tal length/size 7 d G 9 ' FILTER BEDS` _ :Distance to nearest: oundation G Property line ' SEEPAGE LPITS ❑ Depth Size ' I ti Number SUMPS "❑-1 Distance to nearest: Vilell o ndation '1 '7 Property Line T. r a - i DISPOSAL PONDS ❑ - `: r I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.' � i Home owner or licensed agent's signature certifies the following: "I certify that Tn fhe performance'of the work for which this permit is issued,'I shall not 1 employ any person.in such-manner as-to become subject to workman's compensation laws of California.'!,Contractor's hiring or sub-contracting signature certifies the following:'T" ertify that in the performance of the work foi'Alch this'permit is issued,.I shall employ persons subject to workman's compensa- tion laws A� 11 '"T.►"*` •, The applicfor aH regtlired inspecfions. Complete drawing on reverse side. V �---.. ,t[/ 12 t , Date: ' i Signed Title:' a i I A h FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection jby .4kw+k$ Date 3 Final Inspection by Date7 � Additional Comments: ❑'Stk 466 fi781-i �, Lodi 369 3621 ybnteca 823-7104 �; ❑ Tracy 835-6385 Applicant- Return all copies to: Environment Hea ' Permit/Servicesr1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE ',AMOUNT DUE t AMOUNT REMITTED RECEIVED BY DATE PERMWM. INFO CASH71 . A l+EH 13-241REV.10!831 EH 14-28 ,